Assistive Technology Equipment Contract for Individual Student Use

East Central Kansas Cooperative in Education

Loan Agreement

Date_______________________ Student Name_______________________________

Program Representative: ___________________________________________________

School:__________________________________School Phone:____________________

Equipment:______________________________________________________________

Current Replacement Value:________________________________________________

Condition:

I have received the above listed equipment on loan from the East Central Kansas Cooperative in Education. I understand the purpose of this loan is to assist me /my child in attaining stated IEP goals and objectives. I agree to the following conditions:

1. I will participate in orientation/training in order to be able to appropriately use the equipment

2. I will not allow other students to use the device without the teacher’s permission or the permission of an ECKCE representative.

3. I will tell my/the teacher when I have a problem with the device (i.e. if the device is not working properly)

4. I will ask my/the teacher or an ECKCE representative when I have a question about the device

Student’s Signature_______________________________Date:________

Parent’s Signature________________________________Date:________

Note: adapted from Kenosha Unified School District #1, Kenoosha, Wis.

as per ECKCE AT Team Training with Infinitec 2009